Week II
2023-FALL
Caring in Nursing
Practice
OBJECTIVES
•Identifying the steps of nursing process.
•Prioritizing client needs and apply them to the client’s situation. (e.g.,
Maslow’s hierarchy, ABC’s, and safety).
• Identifying definitions of caring.
•Relating the nursing process as it applies to the concept of caring.
• Discussing critical thinking, characteristics, and cognitive skills.
• Applying critical thinking to the nursing process.
• Distinguishing among inductive reasoning, deductive reasoning,
problem solving and decision making.
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AONE Guiding Principles for
Future Care Delivery
3
Theoretical Views on Caring
Caring is primary
Leininger’s Transcultural Caring
Watson’s Transpersonal Caring
Swanson’s Theory of Caring
4
Summary of Theoretical
Views
Nursing caring theories have common themes.
Caring is highly relational.
Caring theories are valuable when assessing patient
perceptions of being cared for in a multicultural
environment.
Enabling is an aspect of caring.
Knowing the context of a patient’s illness helps you
choose and individualize interventions that will actually
help the patient.
5
Patient’s Perspective of Caring
Patients value the affective dimension of nursing care
Caring Assessment Tool
When patients sense that health care providers are sensitive, sympathetic,
compassionate, and interested in them as people, they usually become active
partners in the plan of care.
Assess what your patient expects.
Build a nurse-patient relationship to learn what is important to your patients.
6
Ethic of Care
Caring is an interaction of mutual respect and trust.
The term “ethic” refers to the ideals of right and wrong
behavior.
An ethic of care is concerned with relationships
between people and with a nurse's character and
attitude toward others.
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Caring in Nursing Practice
As you deal with health and illness in your practice, you
grow in your ability to care and develop caring
behaviors.
Caring is one of those human behaviors that we can give
and receive.
Recognize the importance of self-care.
Use caring behaviors to reach out to your colleagues and
care for them as well.
8
Providing Presence
Providing presence is a person-to-person encounter
conveying a closeness and sense of caring.
Presence involves “being there” and “being with.”
Nursing presence is the connectedness between a nurse
and a patient.
Establishing presence strengthens your ability to provide
effective patient-centered care.
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Touch
Provides comfort
Creates a connection
Noncontact touch
Contact touch
Task-oriented touch
Caring touch
Protective touch
Because touch conveys many messages, use it with
discretion.
10
Listening
Necessary for meaningful interactions with patients.
True listening leads to knowing and responding to what
really matters to a patient and family.
To listen effectively you need to silence yourself and
listen with an open mind.
Through active listening you begin to truly know your
patients and what is important to them.
11
Knowing the Patient
The core of clinical decision making and patient-
centered care
Two elements that facilitate knowing are continuity of
care and clinical expertise.
Factors of knowing include:
Time
Continuity of care
Teamwork of the nursing staff
Trust
Experience
12
Spiritual Caring
Spiritual health is achieved when a person can find a
balance between his life values, goals, and belief
symptoms and those of others.
Spirituality offers a sense of intrapersonal,
interpersonal, and transpersonal connectedness.
13
Relieving Symptoms and
Suffering
Performing caring nursing actions that give a patient
comfort, dignity, respect, and peace
Providing necessary comfort and support measures to
the family or significant others
Conveying a quiet, caring presence, touching a patient,
or listening helps you to assess and understand the
meaning of your patient's discomfort.
Comforting through a listening, nonjudgmental, caring
presence
14
Family Care
Caring for an individual
includes a person's
family.
Nurses should help
family members be
active participants.
Learn familial roles.
15
Caring in Nursing
• Caring is the heart of a nurse’s ability to work with people
in a respectful and therapeutic way.
• Caring is specific and relational for each nurse-patient
encounter.
• For caring to achieve cure, nurses need to learn culturally
specific behaviors and words that reflect human caring in
different cultures.
• Because illness is the human experience of loss or
dysfunction, any treatment or intervention given without
consideration of its meaning to the individual is likely to be
worthless
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The Challenge of Caring
Challenges
Task-oriented biomedical model
Institutional demands
Time constraints
Reliance on technology, cost-effective strategies, and standardized work
processes
If health care is to make a positive difference in patients’ lives, health
care must become more holistic and humanistic.
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Critical Thinking in Nursing
Practice
Clinical Judgment
in Nursing Practice
Nurses must make accurate and appropriate clinical decisions or
judgments.
Clinical judgment
Conclusion about a patient’s needs or health problems
Influenced by a nurse’s experience and knowledge
Partly relies on knowing the patient
Influenced by the context of clinical situations and the culture of patient care
settings
Nurses use a variety of reasoning approaches in combination
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Critical Thinking Defined
Critical thinking is:
The ability to think in a systematic and logical manner
A continuous process characterized by open-mindedness,
continual inquiry, and perseverance, combined with a
willingness to look at each unique patient situation and
determine which identified assumptions are true and
relevant
Recognizing that an issue exists, analyzing information,
evaluating information, and drawing conclusions
Evidence-based knowledge in critical thinking
20
Nursing Process Competency
Nursing
process as a
competency
Assessment
Diagnosis
Planning
Implementation
Evaluation
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Developing Critical Thinking
Skills
Reflective journaling
Define and express clinical experiences in your own words
Meeting with colleagues
Discuss and examine work experiences and validate
decisions
Concept mapping
Visual representation of patient problems and
interventions that shows their relationships to one another
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Nursing Assessment
Five-Step Nursing Process
24
Critical Thinking in
Assessment
Gather as much information as possible.
The collection, review, and analysis of data make up the
process of assessment.
Two stages of assessment:
Collection of information from a primary source (a patient)
and secondary sources
The interpretation and validation of data to determine
whether more data are needed or the database is
complete.
Use critical thinking during assessment.
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Critical Thinking in
Assessment
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Types of Assessments
Patient-centered interview (conducted during a nursing
history)
Periodic assessments (conducted during ongoing contact
with patients)
Physical examination (conducted during a nursing
history and at any time a patient presents a symptom)
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Types of Data
Subjective
Patients’ verbal descriptions of their health problems
Includes patient feelings, perceptions, and self-reported
symptoms
Objective
Findings resulting from direct observation
When you collect objective data, apply critical thinking
intellectual standards so that you can correctly interpret
your findings.
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Assessment Data Sources
Patient
Family caregivers and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse’s experience
29
The Nurse-Patient Relationship
in Assessment
Effective communication
Foundation for creating nurse-patient relationships
Trust building
Presence
Rounding
30
The Patient-Centered
Interview
Motivational interviewing
Interview preparation
Communication skills
Courtesy
Comfort
Connection
Confirmation
31
Phases of the Interview
Orientation and setting an agenda
Working phase—collecting data
Interview techniques
Observation
Open-ended questions
Direct closed-ended questions
Leading questions
Back channeling
Probing
Interpret
Termination phase
32
Nursing Health History
Key component of a
comprehensive
assessment
Covers all health
dimensions
33
Cultural Considerations
Cultural competence
Involves self-awareness, reflective practice, and
knowledge of a patient’s core cultural background
Cultural humility
Requires you to recognize your own knowledge limitations
and cultural perspective and thus be open to new
perspectives
Show your patients respect and understand their
individual needs and differences; do not impose your
own attitudes, biases, and beliefs.
34
Professionalism in History
Taking
To display professionalism and a caring approach during
an interview, look at the patient and not the computer
screen.
Use the computer if you must but position it in a way
that does not distract from your focus on the patient.
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Components of the Nursing
Health History
Biographical information Review of systems
Chief concern or reason Observation of patient
for seeking care behavior
Patient expectations Diagnostic and laboratory
data
Present illness or health
concerns
Past health history
Family history
Psychosocial history
Spiritual health
36
Data Documentation
Record the results of the nursing health history and
physical examination in a clear, concise manner using
appropriate terminology.
Baseline to identify a patient’s health problems, to plan
and implement care, and to evaluate a patient's
response to interventions
Record all observations succinctly
Record any subjective information by using quotation
marks.
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The Assessment Process
Data collection
Use information about a patient’s needs to adapt your data
collection.
Interpretation
Critically interpret assessment data to determine whether
abnormal findings are present.
Cues and inferences
Validation
Comparison of data with another source to determine data
accuracy
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The Assessment Process
39
The Assessment Process
40
Concept Mapping
Organize assessment
data
Placing all of the cues
together into the
clusters that form
patterns leads you to
the next step of the
nursing process, nursing
diagnosis
41
Nursing Diagnosis
Types of Nursing Diagnoses
Using standardized terminology is essential for
diagnostic clarity and effective team communication.
Medical diagnosis
Nursing diagnosis
Pathophysiological
Treatment-related
Personal
Environmental
Maturational
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Collaborative Problems
A problem that requires both medicine and nursing
interventions to treat
All physiological complications are not collaborative
problems.
If a nurse can prevent the onset of a
complication or provide the primary
treatment for it, then the diagnosis is a
nursing diagnosis.
44
Terminologies for Nursing
Diagnoses
NANDA International (NANDA-I)
Nursing Intervention Classification (NIC)
Nursing Outcome Classification (NOC)
45
Types of Nursing
Diagnostic Statements
Problem-focused
Risk diagnosis
Health promotion
46
Data Clustering
A data cluster is a set of assessment findings/defining
characteristics.
Compare a patient’s data with information that is
consistent with normal, healthy patterns.
47
Data Interpretation
Involves placing a label on your data pattern or cluster
to clearly identify a patient’s response to health
problems.
Compare the data in a cluster with the data standard
The recognition of data in a logical cluster or pattern
reveals the nursing diagnoses, how a patient is
responding to a health condition or life process.
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Data Interpretation (2 of 2)
49
Formulating the
Diagnosis Statement
Components
Diagnostic label
Related factors
Major assessment
findings
Diagnostic validity
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Use of Nursing Diagnosis in
Practice
Concept mapping
Cultural relevance in
diagnostics
Consider your patients’
cultural diversity,
including ethnicity,
values, beliefs,
language, and health
practices
51
Sources of Diagnostic Error
Errors occur during:
Data collection
Clustering
Analysis and interpretation of data
Diagnostic statement
Guidelines to reduce diagnostic errors
52
Documentation and Informatics
The use of standard, familiar terminology in an EHR can provide nurses
greater ease in their selection of nursing diagnoses and interventions in
planning patient care.
Once you identify a patient’s nursing diagnoses, enter them in the EHR of
the agency.
The agency information system will dictate how the diagnosis is
disseminated throughout the record.
List nursing diagnoses chronologically.
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Nursing Diagnosis
Application to Care Planning
Diagnoses direct the planning process and the selection
of nursing interventions to achieve desired outcomes for
patients.
The care plan is a road map for delivering nursing care
and demonstrates your accountability for patient care.
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Planning Nursing Care
Establishing Priorities
Priority setting
Ordering of nursing diagnoses or patient problems to
establish a preferential order for nursing interventions
Problem-focused diagnoses and problems take priority over
wellness, possible risk, and health promotion problems
Helps you anticipate and sequence nursing interventions
when a patient has multiple nursing diagnoses and
collaborative problems
Establish priorities in relation to their ongoing clinical
importance
56
Critical Thinking in Setting Goals
and Expected Outcomes (1 of 2)
Goal
A broad statement that describes the desired change in a
patient’s condition, perceptions, or behavior
Short-term
Long-term
Often based on standards of care or clinical guidelines
established for minimal safe practice.
57
Role of Patients and Health
Care Team in Goal Setting
Patient collaboration is needed to
Better prioritize goals of care
Develop a realistic and relevant plan of care
58
Expected Outcomes
Selecting goals and expected outcomes
Nursing-sensitive patient outcome
Nursing outcomes classification
Writing goals and expected outcomes
Specific
Measurable
Attainable
Realistic
Times
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Critical Thinking in
Planning Nursing Care
Select interventions designed to help patients the
present level of health described in the goal and
measured by the expected outcomes.
Types of interventions
Nurse-initiated
Health care provider-initiated
Other provider-initated
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Selection of Interventions
Factors to consider
Desired patient outcomes
Characteristics of the nursing diagnosis
Research base knowledge for the intervention
Feasibility for doing the intervention
Acceptability to the patient
Your own competency
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Nursing Interventions
Classification (NIC)
The Iowa Intervention Project developed a set of
nursing interventions that provides a level of
standardization to enhance communication of nursing
care across health care settings and to compare
outcomes.
The NIC model includes three levels—domains, classes,
and interventions—for ease of use.
NIC interventions are linked with NANDA International
nursing diagnoses.
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Hand-Off Reporting
Transferring essential information from one nurse to the
next during transitions in care
Opportunity to ask questions to clarify and confirm
important details about a patient’s plan of care, patient
progress, and continuing needs during the transfer of
information
Focus reports on the nursing care, treatments, patient
goals and expected outcomes documented in your care
plans
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Consulting with Health Care
Professionals
You consult with members of the health care team when you face
problems in providing nursing or collaborative care or in delivering
dependent interventions.
When to consult
How to consult
Successful planning equals patient participation
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Implementing Nursing Care
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Standard Nursing
Interventions
Standard interventions
Allow nurses to act more quickly and appropriately
Help capture patient care information that can be
shared across disciplines and care settings
Nurse- and health care provider–initiated standard
interventions include
Clinical practice guidelines and protocols
Care bundles
Standing orders
Nursing Interventions Classification (NIC) interventions
Standards of practice
66
Standard Nursing
Interventions
Nursing interventions classification interventions
Common interventions recommended for various nursing
diagnoses
Standards of practice
Nurses use the ANA Standards of Professional Nursing
Practice as evidence of the standard of care provided to
patients
Quality and safety education for nurses (QSEN)
Standard competencies in knowledge, skills, and attitudes
for the preparation of future nurses
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Implementation Process
Reassessing a patient
Continuous process each time you interact with the
patient
Reviewing and revising the existing nursing care plan
Revise assessment data to reflect current status.
Revise nursing diagnosis, goals, and outcomes.
Select or revise specific interventions.
Choose methods of evaluation to determine whether
outcomes were met.
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Anticipating and
Preventing Complications
Preventing complications
Identify risks to the patient
Adapt interventions to the situation
Evaluate the relative benefit of a treatment vs. the risk
Initiate risk-prevention measures
Identifying areas of assistance
Seek information about a procedure
Collect all necessary equipment
Consider consequences of performing the procedure
Request another nurse’s assistance and guidance
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Implementation Skills
You are responsible for knowing when one type of
implementation skill is preferred over another and for
having the necessary knowledge and skill to perform
each.
Cognitive skills
Interpersonal skills
Psychomotor skills
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Direct Care (1 of 2)
Activities of daily living (ADLs)
Direct care measures usually performed during a normal
day
Instrumental ADLs (IADLs)
Activities that support daily life and are oriented toward
interacting with the environment
Physical care techniques
The safe and competent administration of nursing
procedures
Lifesaving measures
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Direct Care (2 of 2)
Counseling
Teaching
Controlling for
adverse reactions
Preventive
interventions
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Indirect Care
Nursing treatments or procedures performed away from
a patient(s) but on behalf of a patient
Communicating nursing interventions
Written or oral
Delegating, supervising, and evaluating the work of
other staff members
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Achieving Patient Goals
Nurses implement care to meet patient goals and
expected outcomes.
Priority setting helps nurses to anticipate and sequence
nursing interventions.
Patient adherence means that patients and families
invest time in carrying out required treatments.
Introduce implementation measures that patients are
willing and able to follow.
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Evaluation
Examine Results
Evaluate interventions and outcomes in the areas of
health promotion, prevention of illness and injury, and
alleviation of suffering.
76
Evaluative Measures
Evaluative measures
are assessment skills
and techniques
Evaluating behavior
Self-management
Nursing Outcomes
Classification (NOC)
77
Compare Achieved Effect with
Goals and Outcomes (1 of 2)
Compare clinical data, patient behavior measures, and
patient self-report measures collected before
implementation with the evaluation findings gathered
after administering nursing care.
Evaluate whether the results of care match the
expected outcomes and goals set for a patient.
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Recognize Errors or
Unmet Outcomes
Must have an open mind, actively pursue truth, be
patient and confident, and engage in self-reflection
Apply observational skills, critical thinking intellectual
standards, knowledge, and reflection to recognize the
actual results of care
Self-reflection and correction of errors
Systematic use of evaluation
Correction of errors
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Revising the Care Plan
Discontinuing a care plan
Modifying a care plan
Redefining diagnoses
Revising goals and expected outcomes
Revising interventions
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